Recurrent carotid stenosis. Incidence and management

The actual incidence of recurrent carotid occlusive disease is not known. From January 1974 through December 1984, fifty-four patients underwent at least one second carotid endarterectomy or reconstructive procedure at St. Thomas Hospital in Nashville. Five patients required a third carotid operation. This retrospective study examines case reports, risk factors, patient presentation, interval of recurrence, and pathology involved. Surgical techniques and results are described. Complications occurred in six patients undergoing a total of 66 operations for an overall incidence of 9 per cent. Thrombosis was minimized by the use of antiplatelet drugs. Follow-up of patients ranged from one to 84 months. Four main causes for restenosis are discussed.     

Referral letters: are form letters better?

An essential mode of contact between general practitioners (GPs) and hospital staff is the referral letter. This must be clear and concise with sufficient information to aid the GP, the consultant and the patient. In order to ensure this, a proposal was made for the use of a structured or standardized referral letter: a form letter. This report shows that form letters were shorter than typed letters. Form letters were also proven to contain more information than nonform letters.     

Use of double-pigtail stents in extracorporeal shock wave lithotripsy

Double-pigtail stents are placed commonly in patients before extracorporeal shock wave lithotripsy to prevent ureteral obstruction from steinstrasse. The use of double-pigtail stents in lithotripsy patients with a moderate stone burden was studied in a prospective randomized trial. Patients with unilateral renal stone(s) with at least 1 diameter between 7 and 25 mm. were eligible for the study. Fifty patients were randomized to a control or stented group. Double-pigtail stents with an attached suture were placed immediately before extracorporeal shock wave lithotripsy in the stented group. Stents were removed by the patients 1 week after lithotripsy. A survey on pain and associated symptoms was completed by patients at 1 and 14 days after treatment. There was no statistical difference in flank or abdominal pain, nausea, vomiting, temperature or use of analgesics at 1 and 14 days after extracorporeal shock wave lithotripsy in the control and stented groups. All patients in the stented groups complained of side effects attributable to the stent including urinary frequency and urgency, bladder pain, hematuria and flank pain with urination. Of 25 patients with stents 7 (27%) had early removal because of severe irritation, early migration or accidental removal. Among the patients with follow-up x-rays 1 month after treatment 17 of 21 (81%) in the control group and 12 of 19 (63%) in the stented group showed no evidence of remaining stones. The use of double-pigtail stents is not beneficial in patients with a moderate stone burden. Double-pigtail stents are associated with considerable patient discomfort but no decrease in symptomatic ureteral obstruction or final stone eradication rate.     

Segmental intestinal muscular thinning: a possible cause of intestinal obstruction in the newborn

Intestinal obstruction proximal to a transition zone without an interposed physical barrier usually indicates Hirschsprung disease. The authors report one case of focal small bowel muscular thinning just distal to a transition zone that produced clinical and radiographic findings that simulated long-segment Hirschsprung disease in a 2-day-old infant.     

The meaning of expressed emotion: theoretical issues raised by cross-cultural research.

The finding that expressed emotion is associated with the course of psychiatric disorder has generated a great deal of clinical and research interest in expressed emotion as an important risk factor. Theoretical elucidation of the construct of expressed emotion has lagged considerably behind this interest, however. The authors contribute to a dialogue on what is inside the "black box" called expressed emotion. They argue that cross-cultural research can provide an empirical basis for the theoretical grounding of expressed emotion factors. A comparative approach reveals that the construct of expressed emotion is essentially cultural in nature. The constellation of emotions, attitudes, and behaviors that are indexed by the expressed emotion method represent cross-culturally variable features of family response to an ill relative. Questions surrounding the cultural validity of the construct of expressed emotion, the qualitative dimensions of expressed emotion, and statistically significant cross-cultural variations in expressed emotion profiles are discussed. Finally, the authors provide an outline of diverse (cultural, psychobiological, social-ecological) features of expressed emotion. Anthropological analysis of expressed emotion reveals that although expressed emotion indexes a Pandora's box of diverse features, culture provides the context of variation through which these factors are most productively analyzed.